Abstract
A case of sexual asphyxial death by hanging is presented. A 41-year-old man was found dead hanging by a towrope. A mirror was placed in front of a table, reflecting him in full height. A photograph of a celebrity mannequin was found against him. The towrope was arranged for the compression of the neck, and controlled voluntarily by a shower apparatus. Autopsy findings revealed an ascending ligature mark, 2 cm in width on the neck. Although this is a very ancient behaviour, we are presenting a very rare case from Turkey. We aim to discuss sexual asphyxiation phenomenon together with the features of the previous Turkish cases on the aspect of the forensic viewpoint, as well as the similarities and differences between different nations and religious.

Introduction
Autoerotic asphyxiation is well-known phenomenon described in medical literature, particularly in forensic medicine reports, known as accidental autoerotic deaths. This attitude is defined as a non-psychotic mental disorder where unusual or bizarre imagery acts are necessary for sexual excitement, such kind of imagery or acts tend to be insistently and involuntarily repetitive1.

Although this is a very ancient behaviour, we are presenting the fourth case from Turkey. We aim to discuss sexual asphyxiation phenomenon together with the features of the three previous Turkish cases on the aspect of the forensic viewpoint, as well as the similarities and differences between different nations and religious.

Case Report

A 41-year-old man was found dead hanging by a towrope at the kitchen of a bank's guesthouse (Figure 1). A mirror was placed in front of the table, reflecting him in full height and also there was a broken mirror in the kitchen. The victim was found by a bank's official driver. When the driver opened the balcony door of the kitchen, the mirror which was located leaning against the door was broken. The curtains of the kitchen were drawn and the door was locked. His undershirt was bounded as a brassiere over his nipples and underpants were slipped on his head. The towrope was arranged for the compression of the neck, and controlled voluntarily by a shower apparatus (Figure 1). A photograph of a celebrity mannequin was found against him. His toenails were polished (Figure 2). The victim's body was partially supported by the ground. There were two bottles of[(0)] nail polish and a box of cigarettes on the bed. The deceased lived apparently a normal social life as an inspector of a bank, with a wife married for 12 years and two children. He had been inspecting the branches of the bank and living alone for three months. His wife could think of no reason for him to commit suicide. There was no psychiatric background, no suicide note, and no history of attempted suicide.

Autopsy Findings

The deceased was 173 cm in height and weighed 85 kg. Postmortem hypostasis was marked on the hands and feet. His face was markedly congested and facial petechial haemorrhages were present and also there were many petechial haemorrhages in the conjunctivae. The tip of his tongue had been bitten by his teeth. An ascending ligature mark, 2 cm in width was seen on the neck. There were bruises of the neck muscles and no fracture of the hyoid bone or the thyroid cartilage. Both lungs were congested. There were no pathological findings in organs, except for slight atherosclerosis on the aortic wall and slight left ventricle hypertrophy. Alcohol concentration in the blood was 0.96 mg/ml. The cause of death was attributed to asphyxia by hanging. The manner of death was finally considered to be an accident.

Discussion
Majority of autoerotic asphyxia victims are reported to be adolescent or young adult males.1-5 Even though the three previous Turkish cases were young adults,2-4 the deceased presented in this report was a married middle-aged male.

The autoerotic death scene usually appears in a secluded location, where nobody could disturb or watch the victim,1-5 as was the case in the present report.

One of the important aspect of the psychopathology of autoerotic asphyxiation is "fetishism". While masturbating, individuals may fantasize about the fetish object.5 Women's clothes, and other objects found at the scene include various types of sexual aids: ropes, chains, bars, locks, sex magazines, condoms, plastic bags, rubber items. Individuals may rub, suck, or wear the item or they may insert in into their body orifices.1-5

Approximately 25% of victims were reported to wear female clothes [often female underwear]5 in line with our case and the other three cases in Turkey. This type of attire presumably provides additional impulse increasing the level of arousal.1-4

As in the present case, about half of the cases were married, with a normal sex life and their wives were usually aware of their behaviour.1 In the present case, his wife was not aware of his unusual sexual activities and the victim was engaged in normal sexual life similar to the previous Turkish cases.2-4

The deceased in the present case seemed to want to create a partial asphyxia during masturbation. However, unintentional and prolonged compression of the neck appears to lead to a sudden and unexpected loss of consciousness, probably because of the failure of the self-rescue mechanism.1 Loss of consciousness due to hypoxia, sudden cardiac arrest caused by cardiac sinus reflex, vagal stimulation due to vagal nerve irritation by hanging or rectal dilatation by foreign body, like the case presented by Yemisçigil et al2 were reported.

It is of great importance to clarify the origin of autoerotic asphyxiation death, accident, suicide, homicide from juridical side. In some cases scene reconstruction and psychological autopsy were effective for the differentiation between accident and suicide. Thus, criteria for the differential diagnosis of sexual asphyxia from suicide are very important since the victims may sometimes leave notes that might resemble suicide attempt, as can be seen in the case reported by of Sari et al.4

In the laboratory investigation, it was found that our case was under the influence of alcohol, while in the other three cases, no drug or alcohol was detected in contrast to the cases in literature.1,5

From a psychological viewpoint, it has been suggested that the autoerotic activity results from a castration or separation anxiety6 or a desire for self-punishment for sexual behaviour, rather than from a heightening of sexual pleasure from the self-induced asphyxia.7

According to the anthropologists, Eskimo children are known to hang themselves in a sexual game, Yahgans in South America tied the neck to induce partial strangulation for exhilaration.6 Although this is a very ancient behaviour and some reports have estimated that at least 50-1000 such cases occur each year in United States, or 0.1 cases per million inhabitants per year in Sweden, 0.5 in Denmark, 0.68 in Alberta, Canada,1 and 0.49 in Hannover region, Germany5, we are presenting the fourth case in Turkey. The incidence in Turkey seems to be far lower than that the countries mentioned above, although the precise incidence of such deaths in Turkey is unknown. In the present day, the incidence of sexual asphyxia generally appears to be higher in Anglo-Saxon/Germanic populations, but lower in Japanese, Latins and non-Caucasions.8 This discrepancy may be due to the cultural, ethnic and religious backgrounds, which influence the sexual behaviour of individuals.

A large-scale population survey on autoerotic activity in Turkey does not exist. Studies in student populations show that for 50 percent, the main sexual activity was masturbation.9 In another study, 11.5 percent of female and 87.2 percent of male university students admitted to having masturbated, while 21 percent of the females and 26 percent of the males reported that masturbation was unhealthy.10 Masturbation is commonly regarded as a kind of sin in Islam, as it is in most other religions. Although there is no written rule in the Koran that prohibits masturbation, most people who refrain from autoerotic activities believe that such behaviour is sinful. In the Judaism and Christianity culture, masturbation had been recognized as one of the sexual taboos. Based on the notion of a religious standard for sexual taboos, the differences in the incidences of sexual asphyxia between different communities might indeed be the result of differences of religious background.

The majority of Turkish population is Muslim. Islamic rules are a major determinant in social life and personal attitudes, especially in rural areas. The insufficient.medical information imply that autoerotic activities are not rare among unmarried young males and females in our country.9,10 However, these observations rest on clinical samples and may not reflect patterns of sexual behaviour in the normal population. Attempts to study sexual behaviour in the normal population are hindered by unwillingness on the part of the respondents, because sexuality is still considered as a taboo topic of discussion by the larger part of the Turkish society.9,10

Additionally, autoerotic asphyxial death has been misinterpreted and misdiagnosed for many years because the social stigma and partly because the police and the medical profession are unaware of its existence.1

A certain number of cases may be missed, as the circumstances surrounding the discovery of the victim might not always be clear; evidence may be destroyed by family or friends of the victim out of shame. Therefore, these might be some of the reasons of the rarity of sexual asphyxiation phenomenon in our country.

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